Health Insurance for Individuals and Family
Key Health helps you find the perfect health plan designed around your lifestyle and health.
How do health insurance plans work?
When shopping for a suitable health insurance plan that fits you; it is important to keep in mind the key features that help you decide your budget for health care. These are allocated into five major features:
Premium: a premium is your monthly bill. Every month a premium is paid to a health insurance company; to access the health insurance plan. However, it is not equal to the amount you pay for the health care services.
*You need to understand that choosing a plan with a lower premium will anticipate higher costs toward the out-of-pocket medical bills.
Deductible: Deductibles are the out-of-pocket costs you pay to utilize health care services before the health insurance takes effect. Once the deductible is paid, the health insurance company will use the copayments and coinsurance to split costs with you (up to the out of pocket maximum, after which the plan pays for 100 percent of the services).
*Plans with lower premiums tend to have higher deductibles.
Copayment: A copayment is a fixed amount paid for a specific service or prescribed medication. Copayments are one of the ways that health insurers will split costs with you after you achieve the plan deductible. In addition, you may have copayments on specific services before you reach your deductible.
*For example, many health insurance plans will have copayments for doctor’s visits and prescription drugs before you reach your targeted deductible. You will pay copayments until you arrive at your maximum out-of-pocket limit.
Coinsurance: Coinsurance is another way that health insurers will split costs with you. Unlike a copayment, coinsurance isn’t a fixed cost (it’s a percentage of the cost that you pay for covered services.)
*For example, if you have a coinsurance of 20 percent, you’ll pay 20 percent of the cost of covered services until you reach your out-of-pocket limit.
Maximum out-of-pocket amount: The maximum out-of-pocket amount, is the maximum amount a consumer pays for covered health care services in a year. Payments made toward your deductible, as well as any copayments and coinsurance payments, go toward your out-of-pocket limit and monthly premiums do not count. Plans with higher premiums tend to have lower out-of-pocket limits.
*Note: maximum out-of-pocket is a consumer protection enacted under the ACA; previously plans didn’t have to cap what a person would be required to spend on health care services. This often meant that insured people who had to undergo very expensive treatments (e.g., for cancer or lifesaving surgery) could face unlimited medical bills.
On-exchange private health insurance
A private exchange, is an online store or health insurance marketplace where employees or retirees purchase health insurance and other benefits, typically using funds contributed by their employer. This insurance requires 10 essential benefits that must be covered, also other additional services that are mandated by state governments.
Marketplace (ACA) exchange
On-exchange ACA plans are the only plans for which advanced premium tax credits and cost-sharing reductions (i.e., government subsidies for qualifying applicants) are available.
Off-exchange private health insurance
Off-exchange private health insurance policies are plans that are sold either directly by the health insurance company, through a third-party broker like Key Health Plans, or a privately-run health insurance marketplace.
Off-exchange plans must cover the ten essential benefits and follow other rules dictated by the Affordable Care Act. The caveat with off-exchange plans is that you cannot apply any subsidies (e.g., the advanced premium tax credit or cost-sharing reductions) to these plans. Off-exchange plans allow an insurer more flexibility in plan coverage options and price.
Overall, if you’re shopping for private health insurance and are ineligible for an advanced premium tax credit, looking at off-exchange plans gives you more options at potentially lower price points.
Call us today 1-855-745-5422, an agent can assist you with more information on Individual Family & Health plans. Calling this number will direct you to a licensed insurance agent.
Why is speaking with a licensed insurance agent that specializes in Individual Family & Health helpful? We provide expert guidance on available HMO, PPO, and Indemnity plan options. A licensed agent will educate you on plan features such as physician networks, and cost analysis for the following: premiums, copays, deductibles. Throughout the enrollment process and post-enrollment, you will have a personal contact to assist with questions, claims, or concerns, should any arise.
Types of health insurances
(PPO) preferred provider organization
PPO plans are the least restrictive types of plan when it comes to accessing network of providers and receiving care from outside the plan’s network. Typically, you have two options choosing between:
*An in-network doctor, who can you see at a lower cost
*An out-of-network doctor at a higher cost. You do not need a referral to see a specialist, though you may still choose a primary care physician (some states, like California, may require having a primary care physician).
PPO plans typically have more expensive premiums than other types of private health insurance plans.
(HMO) health maitenance organization
HMO plans are actually networks of doctors and hospitals who agree to give the insured lower rates. The ability to see out-of-network providers is very limited, although they exist. They offer the following:
*When you need to see a specialist or get tests done, you first need a primary care physician to refer you. There may be exceptions.
*There is no coverage offered if you opt to see an out of network provider.
Premiums are lower in average.
(EPO) exclusive provider organization
EPO plans are a mix of HMO and PPO plans. An EPO plan consists of the following:
*Gives the option of seeing a specialist without having to provide a referral
*EPO plans have more expensive premiums compared to HMOs
*EPO plans have cheaper premiums than PPO’s
Note: EPO plans do not cover out-of-network physicians.
(PPO) preferred provider organization
All health insurance plans on government-run marketplaces offer a set of preventative healthcare services, such as shots and screening tests, at no cost to plan members. As of 2018, these are the 18 free preventative services for all adults, as outlined by Healthcare.gov:
*Abdominal aortic aneurysm one-time screening
*Alcohol misuse screening and counseling
*Aspirin use to prevent cardiovascular disease
*Blood pressure screening
*Colorectal cancer screening
*Diabetes (Type 2) screening
*Hepatitis B screening
*Hepatitis C screening
*Lung cancer screening
*Obesity screening and counseling
*Sexually transmitted infection prevention counseling
*Tobacco use screening and cessation interventions
Women and children have their own set of preventative care benefits. For women, many of the free preventative care benefits are related to pregnancy, breast-feeding and contraception, as well as gender-specific cancers and sexually transmitted diseases.
For children, free preventative care is more focused on developmental disorders and behavioral issues, as well as screenings for common chronic illnesses that can develop in children.
There is one period in which consumers can shop for a new health insurance plan on a government-run or private marketplace, known as the open enrollment period. Consumers are unable to purchase a health insurance plan outside of the open enrollment period unless they qualify for a special enrollment period.
Federal open enrollment for 2018 is from Thursday, November 1, 2018, to Saturday, December 15, 2018. If coverage is not purchased during the open enrollment period, consumers may be able to appeal for a special enrollment period, should they qualify.